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General NPI Number Information
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NPI Number | 1528250180
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Entity Type | Organization
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Legal Business Name | DENNIS N. MARSHALL, O.D., P.A.
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Dates
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Enumeration Date | 08/16/2007
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Last Update Date | 02/25/2013
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Provider Practice Location Address
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Address Line | 1495 PARKWAY DR STE A
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City | BLACKFOOT
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State | ID
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Zip | 83221-1639
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Country | US
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Telephone | 208-785-3063
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Fax | 208-782-1392
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Provider Business Mailing Address
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Address Line | PO BOX 40
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City | BLACKFOOT
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State | ID
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Zip | 83221-0040
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Country | US
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Telephone | 208-785-3063
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Fax | 208-782-1392
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Authorized Official
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Title or Position | PRESIDENT
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Name | DENNIS N. MARSHALL
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Credential | O.D., P.A.
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Telephone | 208-785-3063
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | ODP-652
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License Number State | ID
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